Mendoza is wine country. More than 70 percent of the wine produced in Argentina is made in this west central province backing onto the Andes mountain range, and the capital city, also named Mendoza, keeps company with Bordeaux and San Francisco on the list of great wine capitals of the world.
The province is home to around two million people for whom access to quality healthcare is largely determined by location. Angels consultant Romina Delgado says that, with most of the population living in Greater Mendoza and vast distances separating the different urban centers, a telemedicine network conceived in August 2021 was the answer to maximizing the availability of stroke care in the province. And in March this year this network delivered a story so good that it would be a sin not to celebrate it with a glass of the local malbec or chardonnay.
Back when they were planning the network, thrombolysis was available at only two public hospitals, both located in the city of Mendoza. Only one of these, Luis Lagomaggiore Hospital, had a neurology department. Five more hospitals in the province, the furthest of which was 350 km away from the capital, had the potential to become stroke centers but lacked the necessary knowledge and management protocols, leaving a large part of the population vulnerable.
Romina says, “It was in this context of great distances and scarce personnel trained in stroke that the possibility arose for a telemedicine network in which the neurology team in the capital could assist healthcare teams at the peripheral hospitals. Angels would support the progressive implementation of this program by conducting training at each of these institutions in turn, with the aim to optimize human resources, provide better treatment and reduce unnecessary delays and transfers.”
Planning of the network began in August 2021 and in March 2022 the training commenced at the Central Telestroke Unit (UTAC) located in the Luis Lagomaggiore Hospital and the first Peripheral Telestroke Unit (UTAP) located in the Malargüe Regional Hospital, 350 km away. Five month later, on 25 August, the telestroke network, TeleAVC, was formally launched, and the first patient evaluated and treated the following day.
The next two UTAPS joined a year later in August 2023. Hospital Regional Antonio J. Scaravelli in Tunuyán and Hospital Enfermeros Argentinos in General Alvear, respectively 80 and 350 km from Mendoza, were similar to the one in Malargüe. Both had a CT scanner and intensive care unit and offered round-the-clock care, but neither had a neurology department. It was at Hospital Enfermeros Argentinos that this story would unfold.
Dr Federico Giner is a neurologist and stroke coordinator at Luis Lagomaggiore Hospital, and coordinator of TeleAVC in Mendoza. He explains how the telestroke network operates: “Patients are evaluated by the UTPA’s on-call team and if a stroke is suspected, a call to the UTAC neurologist will notify them to go to the telestroke room. The patient is moved to the tomography room for a CT scan and then to the ICU. Here a synchronous video call is established through which the neurologist interacts with the UTAP’s on-call team and with the patient to conduct an NIHSS examination, evaluate the CT scan and complete the checklist.
“If thrombolysis is indicated, a second consultation will be carried out at the end of the infusion during which the neurologist will make recommendations for post-acute care and secondary prevention.”
Three pillars will ultimately determine the future success of the network, Dr Giner says. “Teamwork to empower the UTAP staff, change management, and registration and monitoring of results to facilitate continuous improvement.”
There are still obstacles to overcome, but in March this year the network proved its worth by saving one of its own.
Dr Giner recalls: “It happened on Friday afternoon, 22 de marzo de 2024, a day when I’m usually the teleneuro on duty in the UTAC but on this occasion it was Dr Federico Martínez, a member of the teleneurology staff, who received the call at seven minutes past two. Seven minutes earlier at 2 pm, Dr Alejandro Torres, an anesthesiologist and Executive Director of Hospital Enfermeros Argentinos, upon arriving home had suddenly developed a speech disorder and difficulty walking. Suspecting a stroke, his wife had called the ambulance which delivered Dr Torres to his own hospital at twenty past two, 13 minutes after Dr Martínez took the call.
“A CT scan was performed at 2.34 pm and a subsequent video consultation confirmed an NIHSS score of 4. Dr Torres’s symptoms included facial hypoesthesia, dysarthria and mild aphasia, and he was hypertensive with blood pressure 220/120 mmHg. He was treated with Labetalol until his pressure stabilized and thrombolytic treatment commenced at 2:55 pm, just 55 minutes after symptom onset.”
Although the NIHSS score was low, the symptoms that Dr Torres presented were disabling and, left untreated, would have prevented him from resuming his usual activities, Dr Giner says. “Furthermore, his postural instability was not scored in the NIHSS, a clear example that the NIHSS score should not be the only consideration when making the therapeutic decision.”
Dr Torres’s recovery was swift and within two weeks of the episode he was back at work and presiding over a public ceremony at his hospital. Having been diagnosed with paroxysmal atrial fibrillation he had started treatment with anticoagulents and was otherwise good as new.
Dr Giner says, “There’s no doubt that the coordinated actions of the entire stroke surival chain – from symptom recognition and the actions of both the UTAP’s on-call team and the UTAC neurologist to subsequent care – are the reason Dr Torres received treatment in time.”
A story with such a happy outcome also calls for a toast to Dr Martínez, the young neurologist and former chief resident at Luis Lagomaggiore who was on duty when the telestroke network gave Dr Torres a second chance at life.
